When Is It Appropriate to Use Consultation Codes?

Q: I have seen the codes for "consultation," 99241-99245. Are these codes I should be using whenever I consult with a patient about their care?

A. These codes are commonly misinterpreted because of the description of the code as consultation. Many will mistake the use of consultation in this coding context to indicate the time during or after an evaluation wherein the patient is given a report of findings, treatment plan and recommendations. This "counseling" is actually part of the evaluation and management service codes (99201-99205 and 99211-99215) and is integral to their use. It is not separately billable under the consultation codes 99241-99245.

Under the CPT coding system, a consultation is a type of evaluation and management service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem. It is not used as a code for evaluation and management, nor the counseling associated with it. In simple terms, consultation codes are used to represent second-opinion visits.

If counseling is the component you are looking to code for, it is included in the evaluation and management service. And if counseling is needed outside the initial or follow-up exam, an appropriate established patient E&M service could be used based on the extent of the counseling session.

Guidelines for Billing With Consultation Codes

Here are some guidelines to help you decide if you qualify for use of a consultation code 99241-99245. Documentation must include evidence of the following:

• A third-party-mandated consultation
• Documentation of a request for a consultation from an appropriate source
• Documentation of the need for consultation in the patient's medical record
• One consultation per consultant
• Provision by a physician or qualified nonphysician practitioner whose advice, opinion, recommendation, suggestion, direction or counsel is requested for evaluation and treatment
• recommendations of a patient, since that individual's expertise in a specific medical area is beyond the scope of knowledge of the requesting physician or qualified nonphysician practitioner
• Provision of a written report of findings/recommendations from the consultant to the referring physician or qualified nonphysician practitioner

Consultation codes should not be billed repeatedly or when the consultation is prompted by the patient/family.

The Codes: 99241-99245

99241: Office consultation for a new or established patient that requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

99242: Office consultation for a new or established patient which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

99243: Office consultation for a new or established patient that requires these three key components: a detailed history; a detailed examination; and medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

99244: Office consultation for a new or established patient that requires these three key components: a comprehensive history; a comprehensive examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.

99245: Office consultation for a new or established patient that requires these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family.

Feel free to submit billing questions to Mr. Collins at sam@hjrossnetwork.com. Your question may be the subject of a future column.